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HomeMy WebLinkAbout020-1333-90-000 ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT',` Owner SA tH I Address 40& ED /1'1 A - P 4 r R ! x : City /State b, J4( k) ( � � / �i COUNTY O'er ONING.OFFIC.6 A Legal Description: Lot 1_ Block — Subdivision/CSM # _ZU %a S0 ' / 4 i '►/w, Sec. 27, T Z9 N -R II(Town of rl t1 a Q J PIN # 0 �' d `� 3 3 - �I' b EPTIC TANK -- SE CHAMBER -- HOLDING TANK INFORMATION: / Tank manufacturer ! I Fie- Size ST/P 1 2�'O/ --- Setback from: House Well P/L Pump manufacturer - Model Alarm location (HOLDING TANKS ONLY) Setbacks: Service road —` Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM Type .of system: TGIF I tTO io/L „Width 3 Length u Number of Trenches �-- Setback, from: House 3 3 " Well 1 P/L G'Z' Vent to fresh air intake 0 5 ELEVATIONS Description of benchmark Z • td e. , r U 'T l .`� °j `� Elevation Description of alternate benchmark - r o P a Lt ICK-k- P ,0 A - V r Elevation 1,0 • � *` Building Sewer ST/HT Inlet S S 04. Gr 1 ST Outlet 94 -- ? S ' S ff PC Inlet PC Bottom Header/Manifold +J �S, gTop of ST/PC Manhole Cover A Distribution Lines ( t) q z; - $ 7 : `y, �) �r S - 5`, 7 `= 9 /f° ( ) i Bottom of System ( I) 11 1 I a• t r s. I? 3.53 O Final Grade () Z0 ,D 4 (o / (� (.► +(1 f � � (z? ( ) Date of installation b 4 / ? ?Permit number P 7G q'7 State plan number ° Plumber's sign o ' ° .S� License number 4 � "� �`�� Date Inspector p or Complete plot plan F* Wiscopsin Department of Commerce ' Safety and Buildings Division PRIVATE SEWAGE SYSTEM County:ST . CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitarys r gll : , Personal information you provice may be used for secondary purposes [Privacy La s.15.04 (1)(m)), 3 QQc,t+4it ewer S 's Name : ❑ � lage E] Town of: State Plan ID No.: rMt1lLLlt,,�� CST BM Elev.: Insp. BM Elev.: BM Description: Parcel TUN.i 90-000 l@e� 10(D Td a f Z" 4 TANK INFORMATION ELEVATION DATA A9800036 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Sept �GSelr ( �p Benchmt Dosing /4/f• em Aeration Bldg. Sewer 715 - Holding Ly'� Inlet TANK SETBACK INFORMATION I .a P Ik Outlet 0 1. 001 1:1 $ - TANK TO P/L WELL BLDG. Air Intake ROAD Dt Inlet Septic NA Dt Bottom Dosing NA Header/ Man. t? Aeration NA O ., X -7 S. / Holding Bot. System I ,iy q 3.SI PUMP/ SIPHON INFORMATION Final Grade ( qLT. 3 Manufacturer Demand S'{ •�A,,� t j, 20 R9 •`t S Mo umber GPM TD Lift Friction stem TDH Ft Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED / A rN Width / Lengthq t , No j 0f Tre nches PIT No. Of its Dia. Liquid Depth DIM t! DIMENSION SETBACK SYSTEM TO P/L BLDG WELL LAKE / STREAM LEAC NG Manufacturer: INFORMATION Type 0 < < OR U o el Num System 33 ((b �''- OR UNIT DISTRIBUTION SYSTEM (({� 2bJiKLie✓ 6k.J0tA6t Header / Manifold i � Distribution Pipes) x Hole Size x Hole Spacing Vet To Air Irplake Length 1(0�-Dia. Length Dia. Spacing I W Gv�e�1 SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only [ D ever pth O it Depth Over xx Depth Of xx Seeded / Sodded xx Mulched ed / Trench Center 3i'Q— Bed/ Trench Edges I opsoll LJ r es COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON 27.29.19,SE,NW 661 RED MAPLE LANE Plan revlslon requ red. ❑Yes No �( A Use other side for additional infor atl n. l SBD -6710 (R.3/97) Date pector's Sig ture NOTICE: Please provide the following: • A plan view sketch showing everything within 100 feet of the system. • Two horizontal reference points to center of septic tank manhole cover. • Show alternate benchmark, if applicable. PLAN VIEW �► + . �1t T e r a Y a s It A � ICATE NORTH ARROW ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: SANITARY PERMIT APPLICATION S afety and Buildings Division N4 6consin 2 01 W. Washington Avenue In accord with ILHR 83.05, Wis. Adm. Code P O Box 7302 Department of Commerce Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the system, on paper not less County / than 81/2 x 11 inches in size. J" :(�►'V i x • See reverse side for instructions for completing this application State Sanitary Permit Number 30 74. Y -7 Personal information you provide may be used for secondary purposes Check if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. / && t O( 1e 111(2n& State Plan I.D. Number L APPLICATION INFORMATION -PLEASE ,u P C R II NT ALL INF RMATI N Property Owner Name Property Location �;� SE ,41 1/a /4, S 27 T v—f r N, R/g E ( O ( &) Pr Owner's Mailing Address Lot N ber Block Number is City, State Zip Code Phone Number Subdivision Name or CSM Number tla ( (�g ) �i4D L4 0 S <.� f J�tolDl� II. TYPE OF DI G: (check one) ❑ State Owned !L ❑ !t Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms O Town OF H L) D ] ;,E b A P 14 III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) a7 A9. 7547 1 ❑ Apartment/ Condo i I Facilit 2 ❑Assembly Hall 6 ❑Medical Facility/ Nursing Home 10 ❑ Outdoo r R ec rest ona Fac t y 3 ❑, Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/ Bar/ Dining. 4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash 5 ❑ Hotel / Motel 9 ❑ Office /Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1, ry([ New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System ________ Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non- Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 [] In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 4 3 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation ") 1 7TO —7 0, Feet 9?fp Feet VII. TANK Capacit g all o ns Total # Of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con Steel glass Plastic App g New Existin strutted l 2 Sa Septic Tank o ank Tanks Tank 1�`,, ❑ ❑ ❑ ❑ ❑ Lift Pump Ta /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: No Sta psj MP /MPRSW No.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): 1 07 0 11v WlTrk e OCQ M �So ^I tt,,) 4t1 IX. COUNTY / DEPARTMENT USE ONLY ,fir( pp ❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issui A ent Signature (No Stamps) I/ 1 A roved surcharge fee) �""` ❑Owner Given Initial /J Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD -6398 (R.11/97) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, f lumber T 5l9m �'Y! IL L �;� j?,4 Dc.AA(Vj PRAty.41F LoT � / Sc'H` g IR I i To p1�4i A/r14�Y ✓EA'T. De P Tn RE Qa -71 rs -� .D K 5 z a s r no � T3 p koo rte t4 o aZ F I # 1 NOQ I SLL - ! lt, +Q i L s�t,T vD rte ��tA�E I I t1 � h= - 4) 00 2 U a co _0 v " X co N > s \ x _ N _0 to M C r > > >, 2 x �� u ° 0 o n E N �, a co a� Q _ T Q O N C v = p O N p c 2!, co co W U S _ p O x Q N ctS i� (� ._ O O N _ N � = U a — L�- U x � m N U p - p N t .� , C U. U cz N> O N O _J c0 U- E O S 0 E _ D ® 2) U q 3 ® � u N W I N "s. ® ) 1 T ® U U 1 e � r. N R. c o �) N � U co E Y `° o z � w _ co X �s � 3 O� -c V u> E v z 7 d) LU M oo _ J r O a cn 2! w 7 ' °q° N (` N E co Q. 3 a N 11 I (D W CZ T Y N O> C o U1 m 'Wisconsin Department of Commerce _ _ OIL AND SITE EVALUATION Division of Safety and Buildings Page l of Bureau of Integrated Services 0 cordar a with s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper th� ; Vnches in size. Plan must County include, but not limited to: vertical rizontdl ri&6 (BM), direction and `y f C_ r 4 A percent slope, scale or dimension arrow, and location and distance to nearest road. parcel I.D. # - MAY 1098 APPLICANT INFORMATIO -- ease *Winfor►��Ititn. Revie y Date Personal information you provide maybe V0 secQ6P cy L4v, s. 15.04 (1) (m)). Property Owner Property Location 2 r C� v .i Govt. Lot S 1/4 ,(/loll /4,S T �� ,N,R /O (Ror) W Property Owner's Mailing Address Lo # Block# Subd. Name or CSM# 3 W ( 1-44 k e e TTC'- I ! 5aCQ I CA Aj 1 0 a n -e City State Zip Code Phone Number ❑ City ❑ Village Town Nearest Road 1+ ud sC' Y-, w t ( - 7 �s_) ,S q -G New Construction Use: ERResidential / Number of bedrooms 3 - 5� Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow 60 gpd Recommended design loading rate bed, gpd/ft _ ._ trench, gpd1ft Absorption area required ZS ed, ft 2 _Z4ZO trench, ft _ r� Maximum design loading rate bed, gpd/ft e- � trenc�►, gpd/ft Recommended infiltration surface elevations) 5 7} , S ft (as referred to site plan benchmark) Additional design/site considerations /1 Parent material _ 6—AC C l J o e pcS Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system ® S ❑ U Ps El [� S❑ U I as ❑ U ❑ S O U ❑ S 5"U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 13 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench 1 C-1 /G S/ , mo, f . S a R I Z W lvvriz�z /-(�s /XR bk Y, (."T Y CX Ground 3 0 S r►'� 7 elev. e ft. Depth to limiting M n. 0 i Remarks: Boring # q E ;�- S m C-C r 0A 14' 6 Ground elev. Depth to limiting factor n ffmin. Remarks: /c' e U I I S r d ✓\ CST Name (Please Print) Signature Telephone No. _5c Z L / a ��� �� 3 6_ 3�2 � Address Date CST Number /b 0 3o 0 cam( c-/SO ��/of� 5 - ?,' �. _3 3a Ct SOIL DESCRIPTION REPORT PROPERTY OWNER Page of. PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2 in. Munsell Qu. Sz. Cont. Color > Gr. Sz. Sh. Bed , Trench Ground 3 1�1� _ �� �'— d�'� P1 CA J r 7 elev. Depth to limiting factor &Qjn. Remarks: e Cj ,� S ,�1 r Boring # Ground elev. ft. ' Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # "< Ground elev. ft. Depth to limiting factor in. Remarks: Boring # 13 Ground elev. ft. Depth to limiting factor ' Remarks: SBD -8330 (R. 07/96) 30 e he las"S 2" ,� 6417 -' I - e' ) - /03 S S rh -e l� &A � 5 7 AJ 6�1 Z QI . 43 � o Q � ,g2 � -ej5� 1 - fj�c • ^ "„�� Safety and Buildings Division v ■`■ ■■� SANITARY PERMIT APPLICATION Bureau of Building Water Systems 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County ✓o']x than 8 112 x 11 inches in size: • See reverse side for instructions for completing this application State Sanitary Permit Number 307 &z/7 The information you provide may be used by other government agency programs ❑ Check it revision to previous application (Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Property Owner Name Property Location 5461 Sf 1/4 1/4, S Z7 Z' T ? , N, R 9 E (or) W Property Owner's Mailing Address Lot Number Block Number aiio"t c I City, State Zip Code Phone Number Subdivision Name or CSW Number SQN 11 blrc (3st�►> tX 49 LANDS R 1 /D /( II. TYPE OF BUILDING: (check one) ❑ State Owned 0 cit Nearest Road D Public 1 or 2 Family Dwelling - No. of bedrooms —_3 E] Town OF 1 1 610 0 I /'L 4 4 , III BUILDIN USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 [j Apartment/ Condo 0Zo 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaprant / Bar/ Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash 5 ❑ Hotel / Motel 9 ❑ Office/Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1 New 2, ❑ Replacement 3 ❑ Replacement of 4_ ❑ Reconnection of 5 ❑ Repair of an System System Tank Only______________ Existing System _______ Existing System B) ❑ A Sanitary Permit was previously issued_ Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 210 Mound 30 ❑ Specify Type 41 ❑ Holding Tank 127 Seepage Trench ' 22 ❑ In- Ground Pressure 42 El Pit Privy 13 Seepage Pit 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) d / Elevation 41 6,6 G,O O 7 d Feet Feet VII. TANK Capacit all0 S Total # Of Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturer's Name Concrete Con Steel glass Plastic App New Existing strutted Tanks Tanks '� •�9C (�7� pticTank t� ' WI ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ 10 1 ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: (No Stamps) MP /MPRSW No.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No Stamps) Rj Approved ❑ Owner Given Initial ov Surcharge Fee) Adverse Determination � �00 3 X. CONDITIONS OF PPROVAL L /�� 6 2Vfl o f r I is (33 -Fo li -Fowl o der fI� -� w ac ✓ n S>�i- � v� CPS 1 � SHD -6398 (R. 05/94) DISTRIBUTION: Original to Courtly, One copy To: Safety & Buildings Dive ion, Owner, Plumber • SAM $ADLA X 3 PR A I &IF - Lo'[ ! 4 Cotol MA KE e. -4NE 7 0* 6243- /333 -90 Se,41E l /4j 01 v � v v � v s g -y M A/A Apr �v t3 � �► — � t3- 5 � _ ys , Vj LL) co o c Q N �I o dill �� I 1 CL M Lij IL I I Q � � 0 I �tE d I j � ch L i• w I � Wisconsin Department of Industry SOIL AND SITE EVALUATION Laborand Human Relations Page 1 of 3 Divisidn of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. -qt- Parcel I.D. # APPLICANT INFORMATION - Please fq I ' a f Re / � O ewed by 5 Date Personal information you provide may be used for s ANr!urpo es (Privacy vY .04 (1) (m)). q 82 Property owner �, y t � � r �� roperty Location / C � Richard Stout + `'` ovt. Lot SE 1/a NW "4,s 27 T 29 N,R 10 (or) w Property Owners Mailing Address — w 7 ', L t# Block# Subd. Name or CSM# 1353 Awatukee Trai 19 Badlands Prairie City State Zip Coder ,• Phone NLiiiii��;;r;G- 0 City ❑ Village ® Town Nearest Road Hudson WI 5401st. {', (715 -67� '1r Hudson Pill Farm Rd New Construction Use:] Residential / Nu her of Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow 600 gpd Recommended design loading rate • 7 bed, gpd/ft . — trench, gpd /ft Absorption area required 858 bed, ft 750 trench, ft 2 Maximum design loading rate - 7 bed, gpd/ft • 8 trench, gpd /ft Recommended infiltration surface elevation(s) 97.10 ft (as referred to site plan benchmark) Additional design/slte considerations Parent material Glacial depo sit Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System, in Fill Holding Tank U= Unsuitable for system [2 s -❑ U Ey� S ❑ U 0S ❑ U 0S ❑ U I EIS KJ u ❑ S J] U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed . Trench 1 -16 10yr3/2 none sl lmabk mvfr gs 2f .4 '.5 1,. 2 16-42 1 0yr4 /4 none lfs 1 fabk mvfr Igs if .5 ;.6 Ground 3 42-92 10yr4/6 none ms sg M1 gs elev. - .7 ..8 100. ft. Depth to limiting factor 92 in. Remarks: Boring # 1 -14 10 r3 2 none sl 1mabk mvfr Us 2 2 f —.4 14-43 10yr4/4 none Ifs 1fabk mvfr gs if .5 �.6 3 48-95 10yr4/6 none ms Dsg T11 js - .7 '.8 Ground 102. ft , Depth to -� limiting factor 96 Jn. Remarks: CST Name (Please Print) Signature Telephone No. Address —'-- Date CST Number - 7 e o sy V 77 9Qd Richard Stout SOIL DESCRIPTION REPORT r ROPERTY OWNER Page -- of --3— PARCEL I.D.# 30ring # Horizon Depth Dominant Color Mottles Structure 2 in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed ,Trench 3 _ 2 1 16-46 10yr4/4 none lfs 1fabk nvfr qS if 1.5 ;.6 ,round 3 6 -91 10yr4/6 none ms s 9 T11 gs ?lev. - .7 ..8 10 1 .8 Oft )epth to miting actor 91 W. I Remarks: 3oring # 4 2 16 -48 10yr4/4 none i 1 fabk mvfr gs if .5 ', .6 3 48-98 10yr4/6 none ms osg ml gs - .7.8 Around lev. 107.70ff. )epth to uniting actor 8 in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. MunseN Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # 1 0 -1 10 r3/2 none sl 1mabk mvfr gs 2f .4 .5 5 2 10-45 10yr4/4 none lfs 1fabk mvfr gs if .5 .6 3 45-SO 10yr4/E none MS osg ml gs -- .7 .8 Ground elev. 103 Depth to limiting factor 9 in. Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: SBDW -8330 (R. 08/95) s SC a 12&Zg� o%cf�iNeslatf�il [� �dG SP A n i i p: ,�5 ST CROIX C(J JNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Stf N7 44 /L1.41ZL .,.. Mailing Address ®X s� Property Address (o (op 4 F Q IIIA PL E L sj *F (Verification required from Planning Department for new construction) City/State 14 ✓ la S i° t W � Sy01 Parcel Identification Numbe LEGAL DESCRIPTION Property Location %4, N '/4, Sec. — ? , T N -R /� W, Town of fiw LLS C� - Subdivision RA D LH N D � A l k / ,E. Lot # �. Certified Survey Map # S�o d ((,o — ,Volume (° , Page # Warranty Deed # S'� L/ ?a �{ , Volume ©2- , Page # 3 Spec house 9 yes ❑ no Lot lines identifiable yes ❑ no SYSTEM MAINTENANCE Impiloper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewaterdisposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards .. set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to St. Croix County Zoning Office within 30 days of the three year expiration date. b is /9 S ATURE O APPLICANT DATE ') -WNER CERTIFICATION ,. �I'(we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the apery described above, by virtue of a warranty deed recorded in Register of Deeds Office. F 3 SftRATURE OF PLICANT DATE * * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department.****** ** Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed y 4345 VOL 3�42�dcE�89' 5 57 ` STATE BAR OF WISCONSIN FORM 2 — 1982 WARRANTY DEED DOCUMENT NO. __ R EG I ICE -. 5T• Cif IX Co WI RICHARD O STOUT Ra0 for RQq' q;J MAR 0 51998 conveys and warrants to SAM E MILLER , a Sing 1 e_p -rson , 8.00 A M R AP (a,l THIS SPACE RESERVED FOR RECORDING DATA NAME AND RETURN ADDRESS the following described real estate in St. Croix County, 5 A M M / State of Wisconsin: Lots 19, 20, 35, and 36, Plat of Badlands Prairie, Town of Hudson, St. Croix County, j Wisconsin. PARCEL IDENTIFICATION NUMBER $ �N'FER FEE I I i This is not homestead property. (is) (is not) Exception to warranties: easements restrictions, rights -of -way and covenants of record, if any. Dated this 4th day of March _ , A.D., 1928_ N J" c�) . S' (SEAL) (SEAL) * Richard O. Stout (SEAL) (SEAL) * * AUTHENTICATION ACKNOWLEDGMENT Signature(s) State of Wisconsin, ss. St. Croix County. authenticated this day of 19 Personally came before me this 4t h day of March , 19_q$_, the above named + Richard O. S - tin I� * TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by §706.06, Wis. Stats.) � known to be the person who executed the foregoing ; � pYARY ':;s. ,.. , tl i�tstrume and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY .. .. i ' Janet P. Stout `►`• P V E) 0 ',� I 1353 Awata 0 * Virginia R. Gartman e.. L St. Croix ' � Hudson, Wi . 54016 '1 r at % .y, Notary Public, County, Wis. (Signatures may be authenticated or acknowledged. Both are not My commission is permanent. (If not, state expiration date: necessary) January 30, 2000 ' yq ) t � _ • Names of persons signing in any capacity should by typed or printed below their signatures. STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc. I WARRANTY DEED Form No. 2 — 1982 Milwaukee, Wis.